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Please print in capital letters using black or dark blue ink only. Fill in the circles ( ) like this .

STEP 1: Tell us about yourself.

(We need information about the individual that is the contact person for your case.)

1. First name Middle name Last name Suffix

2. Home address (Leave blank if you don’t have one.) 3. Apartment or suite number

4. City 5. State 6. ZIP code 7. County, parish, or township

8. Mailing address (if different from home address) 9. Apartment or suite number

10. City 11. State 12. ZIP code 13. County, parish, or township

14. Daytime phone number

( ) – 15. Evening phone number

( ) – 16. Do you want to get information about this application by email? ....................................................................................................... Yes No

Email address: 17. What’s your preferred spoken language? What’s your preferred written language?

STEP 2: Tell us about the household member requesting medical assistance.Who do you need to include on this application?Complete pages 2 and 3 for every household member requesting a medical assistance determination. If you are requesting assistance for more than one person, make copies of pages 2 and 3 or provide the information requested on these pages on a separate piece of paper. Completion of the race and ethnicity section of the application is optional.

Children and Family Medical Assistance Supplemental Application

Get help with this form

If you need help completing this form or submitting it to the local Department of Social Services office, please call your local Department of Social Services office and ask for help. A list of local offices can be found at http://dss.sd.gov/offices/.

If you need help completing this form or bringing it to the local Department of Social Services office, please call your local Department of Social Services office and ask for help. A list o flocal offices can be found at http://dss.sd.gov/offices/

DSS-EA-301MA Case#:_____________________ Section: ____1____

......................................................................................................................................................

STEP 2: Tell us about the household member requesting medical assistance. Complete Step 2 for any new household member who needs a Medicaid determination.

1. First name Middle name Last name Suffix

2. Relationship to Contact Person? 3. Are you married?

Yes No

4. Date of birth (mm/dd/yyyy)

/ /

5. Sex

Male Female

6. Social Security Number (SSN) – –We need this if you want health coverage and have an SSN. Even if you don’t want health coverage for yourself, providing your SSN can be helpful since it can speed up the application process. We use SSNs to check eligibility for coverage and, if you apply, for help with coverage costs. For help getting an SSN, call Social Security at 1-800-772-1213, or visit socialsecurity.gov. TTY users should call 1-800-325-0778.

7. Does new member plan to file a federal income tax return NEXT YEAR? You can still apply for coverage even if you don’t file a federal income tax return. YES. If yes, please answer questions a–c. NO. If no, skip to question c.

a. Will new member file jointly with a spouse? .................................................................................................................................................. Yes No

If yes, write name of spouse:

b. Will new member claim any dependents on your tax return? .......................................................................................................................... Yes No

If yes, list name(s) of dependents:

c. Will new member be claimed as a dependent on someone’s tax return? ....................................................................................................... Yes NoIf yes, please list the name of the tax filer: How are you related to the tax filer?

8. Is new member pregnant? Yes a. If yes, how many babies are expected during this pregnancy?

9. Does new member need health coverage? Even if you have coverage, there might be a program with better coverage or lower costs.YES. If yes, answer all the questions below. NO. If no, SKIP to the income questions on page 3. Leave the rest of this page blank.

10. Does new member have a physical, mental, or emotional health condition that causes limitations in activities (like bathing, dressing, dailychores, etc.) or live in a medical facility or nursing home? Yes No

11. Is new member a U.S. citizen or U.S. national? .................................................................................................................................................................. Yes No

12. Is new member a naturalized or derived citizen? (This usually means you were born outside the U.S.)YES. If yes, complete a and b. NO. If no, continue to question 13.

a. Alien number: b. Certificate number:After you complete a and b, SKIP to question 14.

13. If new member isn't a U.S. citizen or U.S. national, do they have eligible immigration status? YES. Enter document type and ID number. See instructions.

Immigration document type Status type (optional) Write your name as it appears on your immigration document.

Alien or I-94 number Card number or passport number

SEVIS ID or expiration date (optional) Other (category code or country of issuance)

a. Has new member lived in the U.S. since 1996? ..................................................................................................................................................................... Yes No b. Is new member, or new member's spouse or parent, a veteran or an active-duty member of the U.S. military? ....................................................... Yes No

14. Does new member want help paying for medical bills from the last 3 months? ........................................................................................................... Yes No15. Does new member live with at least one child under the age of 19, and is new member the main person taking care of this child?(Select “yes” if you or your spouse takes care of this child.) ............................................................................................................................................................ Yes No16. Tell us the names and relationships of any children under 19 that live with new member in your household:

17. Is new member a full-time student? ....... Yes No 18. Was new member in foster care at age 18 or older? ............................................... Yes No

Optional:(Fill in all that

apply.)

19. If Hispanic/Latino, ethnicity: Mexican Mexican American Chicano/a Puerto Rican Cuban Other

20. Race: White Black or African American American Indian or Alaska Native Filipino Japanese Korean Asian Indian Chinese

Vietnamese Other Asian Native Hawaiian Guamanian or Chamorro Samoan Other Pacific Islander Other

If you need help completing this form or bringing it to the local Department of Social Services office, please call your local Department of Social Services office and ask for help. A list oflocal offices can be found at http://dss.sd.gov/offices/

No Due date:

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STEP 2: PERSON 1 (Continue with new member.)Current job & income information

Employed: If new member is currently employed, tell us about their income. Start with question 21..

Not employed: Skip to question 31.

Self-employed: Skip to question 30.

Current job 1:21. Employer name

a. Employer address

b. City c. State d. ZIP code 22. Employer phone number

( ) – 23. Wages/tips (before taxes)

$ Hourly Weekly Every 2 weeks

Twice a month Monthly Yearly

24. Average hours worked each WEEK

Current job 2: (If new member has additional jobs and need more space, attach another sheet of paper.)25. Employer name

a. Employer address

b. City c. State d. ZIP code 26. Employer phone number

( ) – 27. Wages/tips (before taxes)

$ Hourly Weekly Every 2 weeks

Twice a month Monthly Yearly

28. Average hours worked each WEEK

29. In the past year, did new member: Change jobs Stop working Start working fewer hours None of these

30. If new member is self-employed, answer a and b:

a. Type of work:

b. How much net income (profits once business expenses are paid) will you get fromthis self-employment this month? See instructions. $

31. Other income new member received this month: Fill in all that apply, and give the amount and how often you get it. Fill in here if none. NOTE: You don’t need to tell us about income from child support, veteran’s payments, or Supplemental Security Income (SSI).

Unemployment $ How often? Alimony received $ How often?

Pension $ How often? Net farming/fishing $ How often?

Social Security $ How often? Net rental/royalty $ How often?

Retirement accounts $ How often? Other income

Type: $ How often?

32. Deductions: Fill in all that apply, and give the amount and how often new member pays it. If new member pays for certain things that can be deducted on a federal income tax return, telling us about them could make the cost of health coverage a little lower. NOTE: You shouldn’t include child support that new member pays, or a cost already considered in your answer to net self-employment (question 30b).

Alimony paid $ How often? Other deductions Type:

$ How often?

Student loan interest $ How often?

33. Complete this question if new member's income changes during the year, like if you only work at a job for part of the year or receive a benefit for certain months. If you don’t expect changes to your monthly income, skip to the next person.

New member's total income this year

$

New member's total income next year (if you think it will be different)

$

Thanks! This is all we need to know about you. If you need help completing this form or bringing it to the local Department of Social Services office, please call your local Department of Social Services office and ask for help. A list of

local offices can be found at http://dss.sd.gov/offices/

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STEP 3: American Indian or Alaska Native (AI/AN) 1. Is new member an American Indian or Alaska Native?

NO. If no, continue to Step 4. YES. If yes, have any Native American household members requesting medical assistance ever received a service from Indian Health Services (IHS), Urban Indian Health or tribal healthcare? Yes No

STEP 4: New member's health coverage1. Is new member offered health coverage from a job?

Check yes even if the coverage is from someone else’s job, like a parent or spouse, even if they don’t accept the coverage.

YES. Is this a state employee benefit plan? ............................................................................................................................................................................... ... Yes No NO.

2. Is new member enrolled in health coverage now? YES. If yes, continue to question 3. NO. If no, SKIP to Step 5.

If you need help completing this form or bringing it to the local Department of Social Services office, please call your local Department of Social Services office and ask for help. A list oflocal offices can be found at http://dss.sd.gov/offices/

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3. Information about current health coverage. (Make a copy of this page if more than 2 people have health coverage now.)Write the type of coverage, like employer insurance, COBRA, Medicaid, CHIP, Medicare, TRICARE, VA health care program, Peace Corps, or other.(Don’t tell us about TRICARE if you have Direct Care or Line of Duty.)

STEP 5: Mail completed application✉Mail your completed form to: If you want to register to vote, you can complete a A A local Department of Social Services office. voter registration form at www.usa.gov.

A list of local offices can be found online athttp://dss.sd.gov/offices/.

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